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Abstract

Background

Nicotine replacement therapy (NRT) has recently been licensed to help smokers to abstain
from smoking for short time periods and recent studies have shown that 8-14% of smokers
are regularly using NRT to cope when they cannot or are not allowed to smoke. These
data suggest that, potentially, NRT for temporary abstinence might be an acceptable
method to help smoking caregivers, who are not able to stop smoking completely, to
avoid smoking whilst inside their home in order to protect their children from the
harms of environmental tobacco smoke (ETS). The aim of this study was therefore to
explore the concept of using NRT for temporary abstinence in the home, to protect
children from exposure to ETS.

Methods

Qualitative in-depth interviews were conducted with thirty six disadvantaged smoking
parents who were currently, or had recently stopped smoking in the home with at least
one child under the age of five. Parents were recruited from Children’s Centres and
Health Visitor Clinics in Nottingham, UK. Interviews were audio recorded and transcribed
verbatim. Data were coded and analysed thematically to identify emergent main and
subthemes.

Results

Overall, participants responded negatively to the concept of attempting temporary
abstinence in the home in general and more specifically to the use of NRT whilst at
home to reduce children’s exposure to ETS. Many parents would prefer to either attempt
cutting down or quitting completely to make a substantial effort to change their smoking
behaviour. There was limited interest in the use of NRT for temporary abstinence in
the home as a first step to quitting, although some parents did express a willingness
to use NRT to cut down as a first step to quitting.

Conclusion

Disadvantaged smoking parents were reluctant to initiate and maintain temporary abstinence
with or without NRT as a way of making their homes smoke free to protect their children’s
health. More education about the specific risks of ETS to their children and the utility
of NRT for use in the home might be needed to have a public health impact on children’s
health.

Keywords:

Background

Exposure to environmental tobacco smoke (ETS) in children is a major public health
problem, causing serious health consequences [1-3]. Around two million children in the UK are regularly exposed to ETS, with the home
being the main source of exposure. Children’s exposure to ETS is mainly determined
by parental smoking [4]. The magnitude of the problem was recognised in the recent Department of Health’s
tobacco control strategy for England, which aimed to increase the proportion of households
where parents abstain from smoking inside the home from 21% in 2007 [4] to 66% by 2020 [5]. The most reliable way to protect children from ETS in the home is to get parents
to quit smoking altogether. If quitting is not possible, then a complete smoking ban
in the home is the next best option, as partial restrictions, such as smoking in one
room only, are not effective at reducing exposure [6].

Nicotine replacement therapy (NRT) is an effective and widely used treatment for smoking
cessation [7,8]. Some types of NRT are now also licensed for temporary abstinence, that is, to help
smokers to abstain from smoking for short time periods [9]. A recent cross-sectional monthly survey of over 11 400 socio-economically diverse
English smokers found that 14% regularly used NRT for temporary abstinence in situations
when they were not allowed to smoke [10]. This study did not specifically differentiate between enforced temporary abstinence
such as due to restrictions in the workplace and optional temporary abstinence, such
as in private homes. However, this suggests that NRT used for optional temporary abstinence
might be an acceptable method to help smokers, who are not able to stop smoking completely,
to avoid smoking whilst inside their homes. As far as the authors are aware there
have been no studies which have specifically investigated the use of NRT for temporary
abstinence in this particular context. Consequently, this study aimed to determine
smokers’ views about using NRT to help them abstain from smoking in their homes in
order to protect their children’s health. We specifically sought the views of socially-economically
disadvantaged families with children aged under five years because tobacco smoke exposure
is highest amongst disadvantaged children [11] and younger children suffer the greatest morbidity from ETS exposure [1].

Methods

Design

Two sets of qualitative in-depth interview data (n=36) were combined in the current
study to explore the views of smokers with young children on using NRT to abstain
from smoking in the home. One-to-one interviews were chosen in both studies to enable
open discussion of anticipated sensitive social and psychological issues [12-14]. In addition, this allowed the interviewers to offer flexible appointment slots to
fit around the participants’ busy family lives. In the first study, 22 smoking families
were interviewed between July and September 2009. As described previously [15], recruitment was done via Sure Start Children’s Centres which are located amongst
the most socio-economically disadvantaged parts of Nottingham as defined by Index
of Multiple Deprivation, and where the smoking rate was up to 48.1% in recent years
[16]. In the second study, 14 smoking families were interviewed between October and November
2010. Potential participants were identified through six health visitor clinics, which
were randomly selected from the 17 clinics located in areas across Nottingham City
where we had not attempted to recruit families for the first study. The inclusion
criteria for the participants were: age 16 years and over, self-reported current smoker
and currently or recently smoking in the home, caregiver to at least one child under
the age of five, and good level of spoken English. We purposively included parents
who reported no longer smoking in the home. This was partly because other studies
suggest that smoking rules are fluid and therefore self-report of having a smoke-free
home may not be valid [12,14,17]. Secondly, parents who indeed did manage to establish smoke-free homes could provide
invaluable insight into how to successfully implement changes of smoking behaviour
in the home. The interviews took place in a private room at the Children’s Centre
or the health visitor clinic where the participant accessed services or in the participant’s
own home. All participants were offered a £15 retail voucher as an inconvenience allowance
and for potentially having to arrange child care. At the end of the interview each
participant completed a brief demographic and smoking information questionnaire.

These two interview studies form part of a larger body of research which aims to develop
an effective intervention to reduce children’s exposure to domestic ETS. The aim of
the first study was to explore home smoking behaviours, the motivators and barriers
to smoke-free homes, and to identify the positive levers that health care professionals
can utilise when supporting smoking caregivers to change their behaviours. The aim
of the second study was to further investigate the specific details of the intervention,
in particular, to explore in more detail the use of NRT for temporary abstinence in
the home to protect children from ETS. The interview guides were developed from the
literature and through discussions with the Children’s Centre and health visitor staff
that provided the authors with useful insights into the social challenges facing their
clients. The guides were modified further throughout the data collection to incorporate
any new themes. Guide modification was facilitated by immediate post-interview de-briefing
between the interviewers. The first set of interviews was carried out by both LLJ
and OA and the second set of interviews carried out by LLJ and another interviewer.
The discussion guide included exploration of topics around previous quit attempts,
previous and future use of NRT, the concept of temporary abstinence and the use of
NRT for optional temporary abstinence in the home. We anticipated that the concept
of temporary abstinence might be challenging for interviewees to understand and therefore
invested time and effort during interviews to help the participants comprehend this.
Once we were satisfied that participants adequately understood the concept of temporary
abstinence, we explored their views and attitudes towards initiating and maintaining
optional temporary abstinence in their homes in general, and also to using NRT for
optional temporary abstinence in their homes. The participants were also provided
with a NRT summary sheet prior to the interview which included a brief description
of some NRT products. For those participants who had no previous experience of NRT,
we showed them gum and lozenge samples as visual aids. We have previously analysed
the first interview study [15] to show that caregivers had some knowledge of the health risks of ETS exposure for
their children, but that they did have some confusion about, and resistance to these
health messages; in neither study did we provide caregivers with education about health
risks but rather we explored their views and attitudes to temporary abstinence and
NRT in the context of their existing knowledge and experience. This study was conducted
with reference to and adheres to the RATS guidelines for qualitative research [18]. Ethical approval for the first study was sought and gained from the University of
Nottingham Medical School Ethics Committee (ref: A/5/2009) and for the second study
a favourable opinion was given by the Nottingham Research Ethics Committee 1 (10/H0403/18).

Analysis

Data analysis was ongoing throughout the period of data collection and regular discussions
were held between the interviewers and within the rest of the research team. Each
interview was digitally audio-recorded and transcribed verbatim by an external specialist
transcription company. Each transcript was carefully checked for transcription errors
to ensure data quality. Analysis of the transcripts was facilitated by the use of
NVivo software version 8 (QSR International Pty Ltd, Australia). The interviewers
independently generated an open coding framework, utilising the six phase process
of Braun and Clarke [19]. The interviewers independently reviewed each transcript and initial ideas were noted
that identified preliminary codes. These codes were then grouped into potentially
relevant themes and discussed between the researchers and with the wider research
team. Further analysis clarified the specific nature of each theme leading to the
development of names and descriptions. Following the agreement of the themes identified,
extracts were taken from the transcripts to exemplify each theme in order to reflect
the experiences of the participants.

Results

Participants

In total 36 semi-structured interviews were conducted with self-reported smokers.
Although all interviewees were current smokers, they reported a variety of smoking
behaviours within the home. Of the 36 interviews, 27 were with mothers, one with a
grandmother, a resident carer, and eight with fathers. Eighty one per cent were unemployed
or considered themselves to be a house-wife. On average, there were two children living
in each household (range, one to six), and in 48% of the households there were two
or more adult smokers living in the home.

In this manuscript data relating to the following themes are reported:

1. Participants’ attitudes to the concept of optional temporary abstinence from smoking
in the home

2. Participants’ past experiences and perceptions of NRT use

3. Participants’ views about using NRT to help them make their homes smoke-free

Participants’ attitude to the concept of optional temporary abstinence

Overall, most participants were generally negative about the idea of temporary abstinence
in the home. Many did not believe that they could successfully avoid smoking inside
their homes (Table 1, quotes a-b). These participants could not recognise the benefit of “just” stopping
smoking inside their homes and felt that if they were to invest time and effort to
change their smoking behaviour they would prefer to stop smoking altogether (Table 1, quote c). Few caregivers voluntarily raised the subject of their children’s health
in this context. One participant, who aspired to quit smoking altogether at some point
in the future, did suggest that she would consider making her home smoke-free through
optional temporary abstinence, but only as a step towards quitting (Table 1, quote d).

Table 1.Participants’ quotes on the concept of optional temporary abstinence

Experience with NRT

Most participants reported previous use of NRT and understood that NRT provides nicotine
in a medicinal form rather than from cigarettes which helps to overcome the cravings
arising from nicotine withdrawal. However, some were still sceptical about the health
advantages of using NRT instead of cigarettes (Table 2, quotes a-b). Many of the previous NRT users reported positive experiences and had
managed to stop smoking for periods of time, ranging from days to several years. Those
who had relapsed rationalised their negative experiences of NRT in terms of the common
side-effects and its ineffectiveness. For instance, some users attributed their failed
quit attempts to experiencing persistent cigarette cravings despite using high strength
NRT products; others were sceptical about the role of NRT as they felt that their
own willpower was the most important factor. The taste of NRT was also a common problem
– mostly reported for gum, but also experienced with the lozenge and inhalators (Table 2, quotes c-d).

Use of NRT for optional temporary abstinence in the homes

Exploration of interviewees’ previous experiences of NRT often facilitated lengthy
discussions about the potential use of NRT to help the participants make their homes
smoke-free. An overwhelming majority of interviewees expressed generally negative
attitudes about using NRT to help them to avoid smoking in their homes. One of the
participants, a father of one, voluntarily described how he had already managed to
initiate and maintain temporary abstinence to make his home completely smoke free
by using nicotine gum to control his cravings inside the house, even though he was
not familiar with the terminology of temporary abstinence. His reason for stopping
smoking inside the house was his son’s health. However, when asked about the potential
use of NRT by other smokers to help them stop smoking in the home, he promptly talked
about his desire to use NRT to help him stop smoking altogether (Table 3, quotes a-c). Some participants rejected the use of NRT for optional temporary abstinence
because they perceived that stopping completely was the only appropriate way to alter
their smoking behaviour, reiterating previously expressed negativity about the concept
of temporary abstinence itself (Table 4, quotes a-c). Those participants who had already successfully managed to make their
homes smoke-free were also unsure about the value of NRT. These families, as a whole
household, appeared to prioritise their children’s health over smoking indoors. They
felt that understanding the harmful effects of cigarette smoke in the home was a more
important factor. For them, access to NRT alone would not be sufficient to motivate
families to stop smoking in the home. They suggested that NRT use had to be supplemented
by parental education around the benefits of a smoke-free home (Table 4, quotes d-e).

Table 3.Quotes from a participant who successfully used NRT to achieve temporary abstinence
in his home

Table 4.Participants’ quotes on the use of NRT for optional temporary abstinence in the homes

Others were sceptical that using NRT for optional temporary abstinence alone would
not address the more important need to change their smoking routine (Table 4, quotes f-h). One of the participants, a single mother, felt that smoking for her
was more than just nicotine. She was therefore worried that by substituting cigarettes
for NRT she would miss out on the opportunities to have a break and time to herself
(Table 4, quote i). A small group of participants, when asked directly, were initially positive
about using NRT for optional temporary abstinence, however, none gave detailed suggestions
as to why this might be and most only briefly indicated agreement. Those few participants
who gave explanations talked about using NRT in the context of quitting or cutting
down smoking, rather than optional temporary abstinence. The majority of the participants
who rejected the idea of using NRT for optional temporary abstinence, however, reported
being very willing to use NRT in more established and traditional ways, for example,
for quitting or cutting down to quit (Table 4, quotes j-m). This was despite their previous failed attempts and reported side-effects
of NRT.

Discussion

To our knowledge, this is the first study reporting smokers’ views on the value of
trying to achieve temporary abstinence from smoking when in the home and the potential
role of NRT in this context. We found a generally negative attitude both to the concept
of optional temporary abstinence and the use of NRT to achieve it, for a number of
reasons. First, many smokers felt that the strength of their addiction and their deeply
ingrained smoking routines would be too difficult to overcome for them to stop smoking
temporarily whilst inside their home. A number of caregivers also stated a preference
for trying to stop smoking altogether, rather than “just” stopping in the house. Despite
the fact that most of our participants had previously made failed quit attempts, many
would still consider using NRT to help them to quit, either abruptly or after cutting
down.

In our previous analysis, we showed that interviewees had an incomplete knowledge
and confusion about, and a lack of engagement with the effects of ETS on children’s
health [15] and this may have influenced their lack of enthusiasm for optional temporary abstinence.
A UK study from 2003 found that 86% of parents who smoked were aware that ETS was
harmful to their children’s health [6]. Nevertheless, many parents from the same study were using measures to protect their
children from ETS which have been shown to be ineffective, suggesting that many parents
underestimate the risks of ETS. Mothers’ perceptions of children’s health risks from
ETS has been explored in more detail in other studies, which found that they tended
to rely on alternative explanations for ill health unrelated to smoking and falsely
viewed older children as more resilient to the effects of ETS [12,13]. In our study, few caregivers who smoked in the home appeared to link our discourse
about temporary abstinence to their children’s health. Instead, the emphasis amongst
our participants seemed to be around personal goals, such as cutting down or the desire
to stop smoking completely, rather than temporarily abstaining from smoking in their
homes to benefit their children. Conversely, however, interviewees who did not smoke
in their homes believed that knowledge about the harmful effect of ETS on children’s
health and prioritization of children’s health were the key issues to making a transition
to smoke-free homes. This supports the findings from a Swedish study [20] which showed that parental level of evidence based knowledge regarding the potential
risks of ETS to young children might have significantly affected their willingness
to protect their children from ETS. We did not attempt to educate parents about the
health risks of ETS and it is possible that our results would have been different
if we had done so. However, collectively, our findings suggest that providing better
knowledge and understanding of these risks would be an essential part of any future
intervention to promote smoke-free homes.

It is also possible that the failure to engage with the concept of temporary abstinence
in our study group could be partly explained by the relative lack of exposure to situations
where the smokers have to abstain from smoking. Many of our participants were unemployed
or homemakers, and it is likely that they spend less time in situations of enforced
temporary abstinence from smoking than more advantaged households with higher employment
rates where smokers are potentially more used to the concept of enforced temporary
abstinence and could then transfer this approach to their homes. A major strength
of our study is that we explored the views of socio-economically disadvantaged smokers
whose children would, potentially, have the most to gain from reduced exposure to
ETS. However, it is not clear how closely the findings from this sample would relate
to more affluent households where children have less exposure to ETS in the home [11].

Most of our participants had previously tried unsuccessfully to stop smoking, and
therefore may have had more negatively biased views about the use of NRT, which were
described in other studies [21-23]. We found that some resistance to optional temporary abstinence and NRT came from
the complex role of smoking in the lives of these disadvantaged families. Nicotine
addiction per se appeared to play a small part compared to the much-valued need to have a break and
“me” time, which smoking afforded, a finding that is in agreement with previous studies
[13,14]. It was almost seen as “cheating” or cutting corners to use NRT if the smokers were
not determined to radically change their lifestyle. This belief emphasizes the major
effort required of these families to change their smoking behaviour in the home, as
reported elsewhere [24].

Despite the negative views, there was still some support for using NRT to achieve
optional temporary abstinence, as demonstrated by a father who used NRT successfully
to stop smoking in the home and another participant who could see a role for NRT and
optional temporary abstinence as a first step towards quitting. Of note, most of our
failed quitters could still see themselves using NRT in more traditional ways, in
particular, for smoking reduction – either through cutting down, or cutting down to
quit. With appropriate support to ensure smokers cut out the cigarettes smoked in
the home, such smoking reduction could lead to benefits to children, as well as the
smokers’ personal health. A possible implication for healthcare professionals who
are involved with smoking families is that it is important to take a person-centred
approach, exploring smoker’s previous experiences and knowledge about temporary abstinence
and NRT and use them as positive levers to make a permanent change in their household
smoking habits.

The findings of our study provide insight into the relatively unexplored ways of protecting
children from ETS, which could inform any future interventions around smoke-free homes
and ETS exposure. Future research around clinical interventions could explore the
possible effectiveness of education on the risks of ETS and lack of effect of partial
restrictions of smoking in the homes.

Conclusions

Caregivers in our study did not engage with the concept of temporary abstinence as
a means of protecting children from ETS at home. This could be partly explained by
the complex social and psychological aspects of smoking in the lives of these disadvantaged
families but also by a lack of knowledge about the specific health risks to children
of ETS exposure. We also identified a lack of support for using NRT to achieve temporary
abstinence in the home, which may be attributed to people’s incorrect beliefs about
the efficacy of NRT. Nevertheless, our study suggests that there is still a role for
NRT as some families may be receptive to the idea of using NRT for optional temporary
abstinence, and others might be open to using NRT to help them cut down, or cut down
to quit and could be encouraged to do so in a way to protect their children’s health.
These conclusions, however, may only be valid for disadvantaged families.

Abbreviations

ETS: Environmental tobacco smoke; NRT: Nicotine replacement therapy

Competing interest

The authors declare that they have no competing interests.

Authors’ contributions

OA drafted the manuscript, contributed to the development of the interview guide,
carried out interviews and lead the analysis and interpretation of results. TC, AM
and SL were involved in the design of the study and the interview guide, participated
in discussions around interpretation of the results, commented on drafts of the manuscript
and critically reviewed the final version. LLJ contributed to the study design and
interview guide development, carried out interviews, was involved in analysis and
interpretation of results, commented on drafts of the manuscript and critically reviewed
the final version. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank Dr Jo Longman, University of Sydney for her contribution
to the discussions of the project; Miss Sarah Field-Richards for helping to conduct
interviews in the second study; the Children’s Centre and health visiting staff for
their help and support and the families who gave up their time to participate.

Funding

This article presents independent research commissioned by the National Institute
for Health Research (NIHR) under its Program Grants for Applied Research funding scheme
(RP-PG-0608-10020). The views expressed in this article are those of the authors and
not necessarily those of the NHS, the NIHR or the Department of Health. In addition,
this study was supported by core funding to the UK Centre for Tobacco Control Studies
(http://www.ukctcs.org) from the British Heart Foundation, Cancer Research UK, Economic and Social Research
Council, Medical Research Council, and the Department of Health, under the auspices
of the UK Clinical Research Collaboration.

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